ML20274A147

State Agreement (SA) Procedure 100 Implementation of the Integrated Materials Performance Evaluation Program (Impep)

ML20274A147
Person / Time
Issue date:	09/30/2020
From:	Lizette Roldan-Otero NRC/NMSS/DMSST
To:
Modes K
Shared Package
ML20183a179	List: ML20274A147
References
SA-100
Download: ML20274A147 (19)

Text

Office of Nuclear Material Safety and Safeguards Procedure Approval Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

State Agreements (SA) Procedure SA-100 Issue Date:

September 30, 2020 Review Date:

September 30, 2025 Kevin Williams Director, NMSS/MSST Lizette Roldán-Otero, Ph.D.

Acting Branch Chief, NMSS/MSST/SALB Lizette Roldán-Otero, Ph.D.

Procedure Contact, NMSS/MSST/SALB ML20274A147 NOTE Any changes to the procedure will be the responsibility of the NMSS Procedure Contact.

Copies of the procedures are available through the NRC Web site at https://scp.nrc.gov.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 1 of 18 Issue Date:

9/30/20 I.

INTRODUCTION A. This document describes the process for conducting the Integrated Materials Performance Evaluation Program (IMPEP) reviews including scheduling, staffing, and reporting the results of reviews of the Agreement State and U.S. Nuclear Regulatory Commission (NRC) radiation control programs.

B. It is the policy of the NRC to evaluate the Agreement State and NRC radiation control programs in an integrated manner using common and non-common performance indicators, as specified in Management Directive (MD) 5.6, Integrated Materials Performance Evaluation Program (IMPEP).

II.

OBJECTIVES A. To provide the guidelines that will be followed by IMPEP teams when preparing, conducting, and reporting results of IMPEP reviews of the Agreement State or NRC radiation control programs.

B. To provide guidelines for coordination of IMPEP, including facilitating consistency among regulatory programs by interchange of ideas between State and Federal regulators.

III.

BACKGROUND The authority for review of Agreement States is contained in Section 274j(1) of the Atomic Energy Act (AEA) of 1954, as amended. The NRC has programmatic responsibility to periodically review the actions of both the Agreement States and the NRC to comply with the requirements of the AEA. While this authority is reserved to the NRC, the current review process, IMPEP, is conducted with Agreement State staff participation under the National Materials Program0F1. The IMPEP process employs a team of Agreement State and NRC staff to assess radiation control programs of both the Agreement States and the NRC.

IV.

ROLES AND RESPONSIBILITIES The Office of Nuclear Material Safety and Safeguards (NMSS) is the lead office responsible for the implementation of IMPEP. The Division of Materials Safety, Security, State, and Tribal Programs (MSST), within NMSS, has the responsibility for the oversight and management of IMPEP.

A. Management Review Board (MRB)

1. Provides a senior-level review of the IMPEP teams findings and recommendations and issues the final findings to the radiation control program.

2. Roles and responsibilities of the MRB and the guidelines to be followed by the MRB are contained in NMSS Procedure SA-106, The Management Review Board.

1 The National Materials Program is defined as the broad collective effort within which both the NRC and Agreement States function in carrying out their respective regulatory programs for radioactive material (e.g., agreement material).

Agreement Material is defined in Section V. of MD 5.6

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 2 of 18 Issue Date:

9/30/20 B. Director, NMSS

1. Implements the IMPEP within NMSS.

2. Participates as a board member on MRB meetings or delegates the responsibility to the NMSS Deputy Director. If the NMSS Director and Deputy Director cannot attend the MRB meeting, the NMSS Director will delegate the MSST Director as the MRB NMSS representative.

C. Director, MSST

1. Monitors the IMPEP process; evaluates and develops IMPEP policy, criteria, and methodology; and assesses the uniformity and adequacy of the implementation of the IMPEP program;

2. Attends IMPEP review exit meetings, or delegates the responsibility to the Deputy Director or the appropriate Regional Senior Executive Service Manager;

3. Reviews and provides feedback on the draft version of the IMPEP report to the IMPEP Team Leader and IMPEP Program Manager, as appropriate, and reviews and concurs on the final IMPEP report.

4. Attends MRB meetings or delegates to the Deputy Director; and

5. Participates as a board member on MRBs when delegated by the Director of NMSS.

D. State Agreement and Liaison Programs Branch (SALB) Chief

1. Assigns an IMPEP Program Manager;

2. Establishes a schedule and develops a detailed review regimen for conducting IMPEP reviews of the Agreement State and NRC programs;

3. Provides staffing support and training for review teams;

4. Approves IMPEP Team Leader assignments, or assigns a designee to perform this duty;

5. Ensures all personnel acting as IMPEP team members or Team Leaders achieve and maintain qualifications;

6. Reviews and provides feedback on all versions (i.e., draft, proposed final, final) of IMPEP reports to the IMPEP Team Leader and IMPEP Program Manager;

7. Signs the draft IMPEP report to the Agreement State or the NRC program;

8. Signs the proposed final IMPEP report for the Agreement State or the NRC program IMPEP review for consideration by the MRB;

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 3 of 18 Issue Date:

9/30/20

9. Concurs on the final IMPEP report for review and signature by the MRB Chair; and

10. Attends MRB meetings.

E. IMPEP Program Manager

1. Acts as the lead staff for the day-to-day management and oversight of the IMPEP reviews, including tracking the status of reports, maintaining statistical information, interfacing with the Organization of Agreement States (OAS) for Agreement State participants, coordinating NRC staff assignments for IMPEP reviews, and coordinating MRB meetings per NMSS Procedure SA-106;

2. Develops the annual IMPEP review schedule and assigns team members;

3. For non-common indicators, coordinates with the proposed Team Leader and the NRC Regional State Agreements Officer (RSAO), to determine if the non-common performance indicator needs to be reviewed, as applicable;

4. Reviews and provides feedback of IMPEP reports to the IMPEP Team Leader, SALB Chief, MSST management and the MRB;

5. Schedules IMPEP mid-week debrief meetings;

6. Develops and provides annual IMPEP Team Leader and Team Member Training;

7. Prepares proposed final IMPEP reports for the Agreement State or the NRC program IMPEP review and for consideration by the MRB;

8. Coordinates with the OAS to provide appropriate representatives for IMPEP reviews and MRB meetings;

9. Prepares the final IMPEP report for review and signature by the MRB Chair; and

10. Prepares the annual report to the Commission which includes a discussion of the radiation control programs performance, IMPEP status, trending analysis, and other relevant information.

F. IMPEP Team Leader

1. Coordinates and conducts assigned IMPEP reviews;

2. Coordinates on-site review logistics including hotel reservations, transportation for the IMPEP team between the hotel and the program office

3. Requests a meeting room or other suitable location(s) be reserved by the Program management for the team as a base of operations over the course of the on-site review;

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 4 of 18 Issue Date:

9/30/20

4. Coordinates pre-IMPEP and pre-MRB conference calls with the IMPEP Team;

5. Assures and verifies that team members have all the documentation needed to complete their respective indicator(s);

6. Coordinates the IMPEP inspector accompaniments or is actively involved in the selection and planning of inspector accompaniments with the team member assigned the task;

7. Briefs the radiation control programs management undergoing the IMPEP review, on inspector accompaniment outcomes;

8. Designates an IMPEP team member to act as the principal reviewer for each applicable performance indicator;

9. Provides the teams findings to senior level management at the exit meeting and ensures the teams findings are in alignment with MD 5.6;

10. Develops the draft IMPEP report and accompanying transmittal correspondence for IMPEP Program Manager review in accordance with the schedule outlined in this procedure;

11. Completes the IMPEP report in accordance with MD 5.6, and this procedure; and

12. Participates in the MRB meeting for the IMPEP review either in person, or remotely.

G. IMPEP Team Member

1. Completes the review of assigned indicator(s) in accordance with the applicable NMSS procedure(s) and writes corresponding section(s) of the IMPEP report;

2. Briefs the Team Leader of inspector accompaniment outcomes, if assigned inspector accompaniments;

3. Briefs the Team Leader daily on the status of their indicator during the on-site review;

4. Supports other team members to review indicators, as needed;

5. Briefs Program staff on their assigned indicator findings during the staff exit meeting; and

6. Participates in the MRB meeting for the IMPEP review either in person, or remotely.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 5 of 18 Issue Date:

9/30/20 V.

GUIDANCE A. Types of Reviews and Meetings

1. IMPEP Reviews:

a. IMPEP reviews are scheduled every 4 years; however, these reviews may be extended to 5 years if the radiation control program has had two consecutive IMPEP reviews with all indicators found satisfactory (subject to MRB approval);

b. The interval between IMPEP reviews of a radiation control program may be shortened due to performance issues, and at the direction of the MRB, based on the review teams recommendation, or other information obtained during the MRB meeting;

c. Separate trips to perform specific parts of an IMPEP review are permitted and may be advantageous to the radiation control program. Examples are inspector accompaniments and visits to specific licensed facilities. Such activities should be completed prior to the IMPEP review exit meeting;

d. The first IMPEP review of a new Agreement State should be held approximately 18 months after the effective date of the Agreement.

2. Follow-up IMPEP Reviews

a. A follow-up IMPEP review is a limited program evaluation specific to findings from a previous IMPEP review. A follow-up IMPEP review is conducted before the next routine IMPEP review. The purpose of the follow-up IMPEP review is to evaluate a radiation control programs response to recommendations, and to re-evaluate indicator(s) found less than satisfactory.

b. Specific guidance on conducting follow-up reviews is contained in NMSS Procedure SA-119, Follow-up IMPEP Reviews.

3. Special IMPEP Reviews

a. A special review is a review that is performed during an IMPEP cycle. The purpose of the review is to address a specific circumstance or challenge facing a radiation control program.

b. A special IMPEP review should be conducted by an individual qualified to review the IMPEP performance indicator and independent of the radiation control program. Under a special IMPEP review, an indicator(s) may be fully or partially reviewed.

c. A special IMPEP review may be scheduled if:

i.

An Agreement State radiation control program is experiencing serious issues because of the loss of key staff, funding issues, or other acute problem(s) having a major impact upon the program;

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 6 of 18 Issue Date:

9/30/20 ii. An Agreement State radiation control program implements a change (or changes) to its regulations or operating procedures which introduces a conflict of compatibility, or purports to impose its regulatory authority on persons subject to NRC authority; iii. NRC staff are informed about licensee performance issues that could impact public health and safety or security of radioactive materials which would warrant the NRCs immediate attention.; or The MRB directs the evaluation of progress in areas needing improvement identified on a routine IMPEP, follow-up IMPEP.

d. A special IMPEP review for a radiation control program may be scheduled upon request by an Agreement State or the NRC when specific circumstances indicate the need for such a review.

e. A special IMPEP review may be scheduled as directed by the MRB for observations made during IMPEP reviews and periodic meetings.

4. Periodic Meetings

a. Periodic meetings of the Agreement State and the NRC radiation control programs which are typically scheduled at the mid-point between routine IMPEP reviews, are held to ensure that the Agreement States and the NRC remain knowledgeable of their respective programs and to plan for future IMPEP reviews. The meeting also provides an open forum for discussions about a programs status and performance. The interval may be adjusted at the direction of the MRB Chair, based on the IMPEP review teams recommendation or other information obtained during the MRB meeting or review period.

b. Specific guidance on conducting periodic meetings is contained in NMSS Procedure SA-116, Periodic Meetings Between IMPEP Reviews.

c. New Agreement States will have a periodic meeting approximately 9 months after the effective date of the Agreement.

B. Annual IMPEP Schedule

1. Each year, the IMPEP Program Manager will initiate the development of the 12-month review schedule for the upcoming fiscal year.

2. MSST will distribute the proposed schedule to the NMSS Divisions, the NRC Regions, and the Agreement States for their review and comments. Following receipt and resolution of comments, the schedule will be finalized, and copies will be distributed to the NMSS Divisions, the NRC Regions, and the Agreement States.

3. Final schedules are subject to change as circumstances require.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 7 of 18 Issue Date:

9/30/20 C. Assignment of Personnel for IMPEP Reviews

1. The IMPEP Program Manager proposes assignments for Team Leaders, and Agreement State and NRC team members for the upcoming fiscal year based on their qualifications. All assignments are subject to the team members managements approval to ensure their availability and time commitment for the entire review schedule. Assignment of staff to specific performance indicators will be performed in accordance with the qualifications established in NMSS Procedure SA-111, Formal Qualifications for Integrated Materials Performance Evaluation Program (IMPEP) Team Members and Team Leaders.

2. Review assignments are subject to change based on team member availability, need, and special circumstances.

3. IMPEP Review Team Composition

a. For Agreement State program reviews, the review team will be comprised of at least three members: a Team Leader from another Region or NMSS, an RSAO, and at least one Agreement State representative.

b. For NRC program reviews, the review team will be comprised of at least eight members: a Team Leader, NRC staff from another Region or NMSS, and at least half of the team will be Agreement State representatives. The NRC regional team members shall not review any casework related to licensing actions, inspection activities, incidents and allegations from their regional office.

c. The exact size and composition of the review team will be a function of the size and activities of the program being evaluated. The IMPEP Program Manager will provide additional guidance on the composition of each specific IMPEP review team. IMPEP team members should be independent of the program being reviewed. IMPEP Team Leaders should not lead consecutive IMPEP reviews for the same program.

4. Agreement State Personnel

a. Agreement State participation is coordinated between the Organization of Agreement States (OAS) and NMSS.

b. Specific guidance on Agreement State participants in IMPEP is contained in NMSS Procedure SA-120, Agreement State Participation as IMPEP Team Members.

5. Special Circumstances during IMPEP Reviews

a. Staff assignments may be made because of known or potential performance issues in certain aspects of a radiation control program. In such cases, a staff member with specialized training or experience in the appropriate field may be assigned to assist. Alternatively, technical assistance from Agreement States or other NRC offices may be provided. In all cases, the qualifications detailed in SA-111 shall be followed.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 8 of 18 Issue Date:

9/30/20 D. Scheduling IMPEP Reviews

1. The Team Leader should contact the appropriate management level at the Agreement State (usually the Program Director) or the NRC (usually the MSST Division Director) to set the date for the program review per the designated schedule. This scheduling should be completed as soon as possible on the issuance of the annual IMPEP schedule, but at a minimum of 120 days before the review. Team Leaders are encouraged to make early contact with the Agreement State or the NRC to reserve the review dates with the understanding that details (e.g., inspector accompaniments, site visits, etc.), will be established later. The Team Leader should indicate the time frame of the MRB meeting based on the established review dates. The MRB meeting should be held between 90-105 days after the exit meeting.

2. Team Leaders are encouraged to utilize the RSAO assigned to the Agreement State when coordinating the IMPEP reviews.

3. Inspector accompaniments or visits to State licensed facilities should be scheduled following the guidance in NMSS procedure SA-102, Reviewing the Common Performance Indicator, Technical Quality of Inspections (TQI).

E. Scheduling Letter and Questionnaire for IMPEP Reviews

1. At least 120 days prior to a routine IMPEP review, the Team Leader should send, electronically, the current IMPEP questionnaire to the Agreement State or NRC radiation control program along with correspondence requesting that the completed questionnaire be returned at least 2 weeks before the on-site review.

The most recent version of the scheduling correspondence and the IMPEP questionnaire (as approved by the Office of Management and Budget) can be found at https://scp.nrc.gov/impeptoolbox/impepquestionnaire.pdf. No printed copies of the questionnaire will be mailed.

2. For Agreement State radiation control programs, the questionnaire will include questions involving all of the common performance indicators, the non-common performance indicator: Legislation, Regulations, and Other Program Elements, and any of the additional areas where the Agreement State has regulatory jurisdiction (e.g., Sealed Source and Device (SS&D) Evaluation Program, Low-Level Radioactive Waste (LLRW) Disposal Program, or Uranium Recovery (UR)

Program).

3. For the NRC radiation control program, the questionnaire will include questions involving all of the common performance indicators, and the two non-common performance indicators: SS&D Evaluation Program, and UR Program.

F. Preparation for IMPEP Reviews

1. Prior to the on-site review, the Team Leader and team members should review the following documents to identify existing or potential problems, to ensure these issues can be fully discussed and reviewed:

a. The Programs response to the questionnaire;

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 9 of 18 Issue Date:

9/30/20

b. The previous IMPEP report(s) (including special or follow-up reviews) and the Agreement States or NRCs response to the report since the last full review. (Note: the minutes for the applicable MRB meeting should also be reviewed for any changes or comments directed by the MRB that were not reflected in the final IMPEP report);

c. A list of incidents from the Nuclear Material Events Database (NMED) for the specific Agreement State or NRC since the previous IMPEP review;

d. The most recent periodic meeting summaries held since the previous IMPEP review. (Note: the minutes for the applicable special MRB meeting should also be reviewed for any changes or comments directed by the MRB that were not reflected in the summary report);

e. For Agreement States, a printout of the States regulation status from the State Regulations Status Data Sheet maintained by MSST;

f.

For Agreement States monitoring or heightened oversight call summaries, if applicable, for all meetings since the previous IMPEP review;

g. For Agreement States, a printout or listing of all allegations referred to the State by the NRC should be obtained from the RSAO and the NMSS allegation coordinator dating back to the previous IMPEP review; and

h. Other documents or files relating to Agreement State or NRC activities, such as abnormal occurrence reports, technical assistance requests and responses, and pending requests for information.

2. If repetitive problems or issues were identified during the previous review or other interactions, the team should review any additional documents that may help determine possible root causes of the repetitive problems or issues.

3. Prior to the on-site review, the Team Leader should request information from the program as to the type of files (paper or electronic) that the team will encounter during their casework review; and any associated training, passwords, etc. that will be necessary to access the files. For applicable Agreement States and the NRC, the Web-Based Licensing (WBL) system may be used to review case files.

The Team Leader should contact the NRC to make arrangements for the reviewing of electronic files by an Agreement State team member at least 120 days prior to the on-site review.

4. One week prior to the on-site portion of the IMPEP review, the Team Leader and IMPEP Program Manager will host a teleconference with the review team to coordinate final arrangements and to discuss any emerging issues. Emerging issues may include additional areas requiring review, additional specific guidance, or specific correspondence that may be beneficial to review prior to the on-site review.

5. The time, location, and list of participants for the exit meeting should be finalized, if possible.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 10 of 18 Issue Date:

9/30/20

6. A checklist for the Team Leader to assist in preparation for the IMPEP review is available in the IMPEP Toolbox on the state communications portal Web site.

G. Entrance Meeting

1. During the entrance meeting for the on-site portion of the IMPEP review, the Team Leader should present the purpose and the scope of the review, introduce the team members and their respective areas of review, and describe the general timeline and sequence of activities.

2. The Team Leader should request introductions of the radiation control program management and staff.

3. Information which was requested but not previously furnished by the radiation control program should be obtained.

4. Additional meetings (e.g., daily meetings with radiation control program management or additional exit meetings) should be discussed.

5. Accompaniments of inspectors and visits to licensed facilities conducted prior to the on-site review should be mentioned.

6. The Team Leader should be prepared to discuss items of current interest to Agreement States or the NRC. This could include new information such as changes in NRC licensing and inspection procedures, proposed changes to NRC organization and administration, new regulations affecting the Agreement State programs, new training programs, changes or innovations by the Agreement State, etc.

H. On-Site Portion of the IMPEP Review

1. Specific guidance for reviewing the common performance indicators is contained in NMSS Procedures SA-101 through 105 which are available in the NMSS procedures tab on the state communications portal Web site.

2. Specific guidance for reviewing the non-common performance indicators is contained in NMSS Procedures SA-107 through SA-110 which are available in the NMSS procedures tab on the state communications portal Web site.

3. Questions regarding information provided in the response to the IMPEP questionnaire should be discussed, and corrections should be made, if necessary.

4. Periodic meeting reports, previous IMPEP review reports, and questionnaire responses should be used to focus the review on any potential program issues.

a. The review team should evaluate any follow-up actions taken and the current status of any previously identified program issues during the on-site review.

b. The status of open recommendations from previous IMPEP reviews should be evaluated for closure or modification.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 11 of 18 Issue Date:

9/30/20

5. The review team should have access to all the information necessary to document and evaluate the Agreement State's or NRC's performance relative to each applicable performance indicator. However, team members should not retain or remove any documents containing sensitive information from the facility.

6. Upon direction of the MRB Chair or NMSS management, the review team may need to obtain additional or more detailed information. Such a request may be specific to the Program being reviewed or may be generic, as appropriate.

7. Identification of Performance Issues

a. Individual team members should discuss casework performance issues with the license reviewer or inspector whenever possible, and the Team Leader, if it is determined that these issues are programmatic in nature.

b. The Team Leader should discuss any programmatic performance issues with the radiation control program management as they are identified, ideally on a daily basis during the on-site review.

c. In the discussions with the radiation control program management, the Team Leader and review team should seek to identify and understand the root cause(s) of the programmatic performance issues. This can serve as the basis for developing recommendations for corrective actions. Criteria and Examples of Recommendations can be found in the IMPEP Toolbox on the state communications portal Web site.

d. The review team should determine the indicator areas under which each programmatic weakness falls and determine whether the weakness is a significant problem.

e. The review team may identify practices that could enhance the radiation control program. These discussions should be documented in the IMPEP report.

f.

When a finding relates to a potential risk-significant health and safety, or security issue (e.g., as an omission of a critical element of a safety plan for a facility), the issue should be brought to the attention of the Program immediately and dealt with as soon as possible. The review team should attempt to obtain the corrective actions the Program has taken, or plans to take, and incorporate this information into the IMPEP report.

g. The review team may also identify shortcomings or issues in the NRCs oversight program. These issues should be brought to the attention of the Team Leader and documented in the IMPEP report.

8. For programs where the agreement only includes non-common performance indicators (e.g., LLRW Disposal program, or UR program).

a. Review each sub-element independently as a common performance indicator and attribute a rating to each indicator.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 12 of 18 Issue Date:

9/30/20

b. Specific guidance for reviewing the non-common performance indicators is contained in NMSS Procedures SA-109 and SA-110.

c. Legislation, Regulation, and Other Program Elements will be evaluated as a non-common performance indicator as specified in NMSS Procedure SA-107.

d. Overall adequacy and compatibility will be determined in accordance with the rating attributed to each sub-element as described in MD 5.6.

9. If the conduct of a team member is disruptive to the review, the Team Leader is to bring this matter to the attention of the IMPEP Program Manager, SALB Chief or MSST management immediately.

I.

Third Party Attendance in IMPEP Reviews

1. Agreement States IMPEP reviews are audits between regulatory partners and conducted in compliance with Section 274j(1) of the AEA of 1954, as amended.

Members of the public or media may learn of a review and ask to attend all or parts of a review. These requests should be referred to the Agreement State Program management since the review activities (other than field activities) take place in State offices.

2. If the public or media is permitted by an Agreement State to attend, the NRC position is that they may observe and may offer comments or questions at the conclusion of the review teams summary presentation. In some cases, the review team may arrange for a separate meeting with the public or media representatives to answer their questions. The review team should state that the findings of the IMPEP review are preliminary, and that the MRB will deliberate the findings in a public meeting. Questions regarding the IMPEP and MRB processes can be referred to the IMPEP Program Manager.

3. In all cases where public or media representatives request attendance at, or are allowed to attend reviews, IMPEP project management should promptly inform the SALB Chief and the Office of Public Affairs.

J. Reviews of the NRC Program are considered internal management reviews. As such, reviews are not subject to the requirements for public notice, nor are they normally accessible to public attendance. Summarizing IMPEP Review Findings

1. For the evaluation criteria for each performance indicator and overall program findings, refer to MD 5.6 and NMSS Procedures SA-101 through SA-105 and SA-107 through SA-110. Team members should familiarize themselves with the overall performance criteria determination for their performance indicator prior to the IMPEP review. Team members evaluating a given performance indicator will provide their findings to the Team Leader and team members with their overall performance criteria determination, in accordance with MD 5.6.

2. The impact of issues in one performance indicator could have a negative impact on performance in other indicators. As a general matter, a performance deficiency, and associated root causes, should be assigned to only the most

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 13 of 18 Issue Date:

9/30/20 appropriate indicator and not counted against multiple indicators. The primary decision for the determination of each performance indicator finding is the responsibility of the team member qualified to perform the evaluation. Team members will present their findings and final evaluation to the Team Leader and other IMPEP team members. During this presentation, the team will have an opportunity to ask questions regarding the findings. The purpose of the presentation is to ensure the team member has a clear understanding of the findings, can articulate the findings in a clear and concise manner, and that the determination of the finding is in accordance with MD 5.6. In addition, it is an opportunity to prepare for MRB inquiries regarding the performance indicator.

3. In terms of general guidance for the IMPEP review team, a finding of "satisfactory" should be considered when none or only a few or small number of the cases or areas reviewed involve performance issues/deficiencies (e.g.,

inspection, licensing, staffing, etc.); an "unsatisfactory" finding should be considered when a majority or a large number of cases or areas reviewed involve performance issues/deficiencies, especially if they are chronic, programmatic, and/or of high-risk significance; and a finding of "satisfactory, but needs improvement" should be considered when more than a few or a small number of the cases or areas reviewed involve performance issues/deficiencies in high-risk-significant regulatory areas, but not to such an extent that the finding would be considered unsatisfactory. Specific guidance and examples pertaining to each finding can be found in the IMPEP Toolbox on the state communications portal Web site for each applicable performance indicator.

4. The overall performance findings for adequacy and compatibility of the radiation control program should be determined through team consensus. In reaching this consensus there should be an open collaborative environment where each team member can ask questions, express differing views, and where ultimately the team can agree on a decision that all members can support.

5. If the team cannot reach a consensus, the report should reflect any difference of opinion to ensure the MRB is aware of the issue. In addition, if a team member decides to formally document a difference of opinion, the Team Leader should consult with the IMPEP Program Manager to ensure that the differing opinion is documented consistent with Management Directive 10.159, NRC Differing Professional Opinion Process.

6. The Team Leader should hold debriefs regarding the results of the Program review at both staff and management levels for Agreement States and the NRC.

7. An NRC Senior Executive Service NRC manager from NMSS or the applicable NRC Regional manager will attend all Agreement State IMPEP review exit meetings. The IMPEP Team Leader should brief NRC management prior to the exit meeting on the preliminary findings of the review. The NRC manager will deliver opening remarks during the exit meeting with Program senior management.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 14 of 18 Issue Date:

9/30/20

8. Comments (e.g., remarks or observations) are intended to be constructive and to promote improvements. Comments made during meetings on the review findings should be made in programmatic terms and should not, to the extent possible, reflect on individual performance.

9. The Team Leader is responsible for assuring that ample time is provided for:

(1) radiation control program staff to express their reactions to the comments; and (2) full discussion of the preliminary findings with staff and management.

Any disagreements with the comments should be acknowledged by the Team Leader.

10. On-going discussions should be at the working staff level during the on-site review period. It may be advantageous to hold a summary discussion with the entire materials staff at the conclusion of the review.

a. The discussions should be in enough detail to ensure the inspector or the license reviewer and immediate supervisors are aware of each specific issue, the reason it was considered an issue, possible root cause(s), and the Programs corrective actions taken or planned to be taken.

b. Actions by the staff which are considered to be meritorious should be discussed.

c. Good practices identified by the review team should be noted and documented in the report. Previous examples of a Good Practice can be found on the IMPEP toolbox on the state communications portal Web site.

11. The first level of discussion with radiation control program management should be with the Director of the Radiation Control Program or the appropriate NRC Division Director, and supervisors.

a. The review team should discuss the comments and recommendations for each indicator and whether or not each finding is significant. These discussions should be limited to the performance issues and their corrective actions.

b. Items or areas considered meritorious should be emphasized.

c. The review team should identify the recommendations that will be made to the senior managers1F2, or designee, at the scheduled exit meeting.

d. If one or more significant issues exist with respect to the performance indicators, the Director should be informed that improvements in these areas are critical and that recommendations will be made to the MRB. The MRB Chair will make the final decision on program adequacy and compatibility.

2 Senior Manager: For the radiation control program, the senior manager is the government executive who receives the final IMPEP report.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 15 of 18 Issue Date:

9/30/20

12. The final level of discussion should be with the senior managers.

a. The summary discussion with the senior manager should normally be confined to those items expected to be included in the formal review report.

b. The discussion should be sufficient to explain that other comments relating to the technical aspects of the program were discussed with the Director during the review meeting and were resolved. If requested, the Team Leader or individual team members should be prepared to cover these findings in the discussion. An on-site summary discussion guidance is available in the IMPEP Toolbox on the state communications portal Web site.

c. Good practices identified by the review team should be noted.

d. If significant issues exist in one or more performance indicators, the Team Leader should inform the Programs senior manager that the need for improvement in these areas is critical and that recommendations to the MRB will reflect this fact.

e. The Team Leader should state during the summary meeting that all findings are preliminary until deliberated by the MRB and approved by the MRB Chair, and that formal recommendations will be provided in the final report.

In all cases, the Team Leader should inform the Programs senior manager that the MRB Chair makes the final decision on program adequacy and compatibility.

f. If one or more significant issues are found, a summary meeting or discussion should be held with the senior manager rather than with his or her designee, if possible.

K. Draft and Proposed Final Reports

1. The Team Leader is responsible for preparing the draft report following an IMPEP review.

2. The review team members should complete assigned sections of the draft report and submit them to the Team Leader according to the timeline established by the Team Leader, but no later than 7 calendar days after the last day of the review.

a. The casework evaluated may be incorporated into the report as an appendix, when the team recommends a finding of satisfactory, but needs improvement for one or more indicators.

b. The casework evaluated must be incorporated into the report as an appendix, when the team recommends a finding of unsatisfactory for an indicator.

c. Comments regarding evaluated casework that will appear in the reports appendix should be factual, concise, and concentrate on casework deficiencies and their root cause(s).

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 16 of 18 Issue Date:

9/30/20

3. The Team Leader is responsible for integrating the information from the team members and developing a draft report to be shared with the review team for their comments.

4. After receiving and resolving comments from the review team, the Team Leader is responsible for submitting both the draft report and transmittal correspondence to the IMPEP Program Manager and the SALB Chief for review and comment within 18 calendar days after the last day of the review.

5. The draft report and transmittal correspondence should be transmitted to the radiation control program within 45 calendar days after the last day of the review with concurrence from the Team Leader. A copy of the draft report should also be sent to the RSAO assigned to that Agreement State.

6. If the team did not reach a consensus and a team member declines to concur on the draft report, that team member needs to refer to MD 10.158 and follow the non-concurrence process within 18 calendar days. If the team member is from an Agreement State, the Team Leader should contact the IMPEP Program Manager for guidance.

7. The radiation control program will be requested to review the draft report and address any factual errors or misstatements within 4 weeks from receipt of the draft report.

8. Upon review of the radiation control programs response, the Team Leader will be responsible for making any appropriate corrections. If the comments are extensive, a separate comment resolution document should be prepared by the Team Leader for submittal to the MRB. A comment resolution table template is available in the IMPEP Toolbox on the state communications portal Web site.

9. The IMPEP Program Manager or designee will coordinate the scheduling of MRB meetings for radiation control program IMPEP reviews in consultation with the Team Leader. A copy of the radiation control programs comments on the draft report will accompany the proposed final report presented to the MRB.

L. MRB Meeting

1. MRB meetings are to be conducted approximately between 90-105 days from the last day of the IMPEP review, including follow-up and focused IMPEP reviews, in order to achieve the timeliness goals. The NRC has a timeliness metric of issuing the final report within 30 days of the MRB meeting.

2. If the radiation control program has significant issues identified in one or more performance indicators, the Team Leader and the team member for that specific performance indicator should attend the MRB in person, if possible. Team members should make all reasonable attempts to attend the meeting remotely via.

3. The agencys virtual meeting platform. Otherwise, the team member should call in for the meeting to present their performance indicator.

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 17 of 18 Issue Date:

9/30/20

4. The Chair of the MRB will make the final determination regarding the overall assessment of the Agreement State's or NRCs program as an outcome of an IMPEP review and the MRBs deliberations. If the radiation control program disagrees with the MRB Chairs decision to continue or enter a period of monitoring or heightened oversight, the radiation control program may appeal that decision to the Executive Director of Operations (EDO) within 7 calendar days of the issuance of the final MRB report.

5. Specific guidance on conducting MRB meetings, additional guidance on the proposed final report, and the appeals process is contained in NMSS Procedure SA-106.

M. Issuance of Final Reports and Follow-up Actions

1. The SALB Chief and the IMPEP Program Manager, in consultation with the Team Leader, will be responsible for preparation of the final report and transmittal correspondence to the Deputy Executive Director for Materials, Waste, Research, State, Tribal, Compliance, Administration and Human Capital Programs for signature.

2. Program responses to recommendations made in the IMPEP report will be evaluated by the IMPEP Program Manager or designee and the Team Leader in consultation with the review team.

3. An acknowledgment letter shall be prepared by the IMPEP Program Manager or designee within 30 days after receipt of the response to recommendations.

VI.

REFERENCES IMPEP Toolbox (containing the Checklist for the Team Leaders to Assist in Preparation for IMPEP Reviews, On-Site Summary Discussion Guidance, Comment Resolution Table Template, and Criteria and Examples of Recommendations) are available at https://scp.nrc.gov/impeptools.html Management Directives (MD) are available at https://scp.nrc.gov NMSS SA Procedures are available at https://scp.nrc.gov VII.

ADAMS REFERENCE DOCUMENTS For knowledge management purposes, all previous revisions of this procedure, as well as associated correspondence with stakeholders, that have been entered into the NRCs Agencywide Document Access Management System (ADAMS) are listed below.

No Date Document Title/Description Accession Number 1

1/28/00 SP-00-008, Draft OSP Procedure SA-100, Implementation of IMPEP ML003680423

SA-100: Implementation of the Integrated Materials Performance Evaluation Program (IMPEP)

Page: 18 of 18 Issue Date:

9/30/20 No Date Document Title/Description Accession Number 2

7/11/00 STP Procedure SA-100, Implementation of IMPEP ML011230502 3

7/25/00 Summary of Comments on SA-100 ML011230545 4

8/8/06 STP-06-070, Opportunity to Comment on Draft Revisions to STP Procedure SA-100 ML062210006 5

8/8/06 Draft STP Procedure SA-100 ML062210010 6

12/19/06 Summary of Comments on SA-100 ML070370201 7

2/1/07 STP Procedure SA-100 ML070360578 8

12/17/19 NMSS Procedure, SA-100 ML19345D619 9

9/29/20 Resolution of Comments ML20183A152 10 9/30/20 Final NMSS Procedure SA-100 ML20274A147